Cervical spine radiographs in patients with rheumatoid arthritis undergoing anesthesia

Background: There is no consensus on the role of preoperative cervical spine radiographs to screen for instability in patients with rheumatoid arthritis (RA). Objectives: This study aimed to evaluate the preoperative use of cervical spine radiographs in patients with RA undergoing preoperative anesthesia assessment and to determine whether preoperative radiographic findings influenced anesthesia delivery techniques. Methods: We reviewed all medical records of RA patients who underwent surgical procedures requiring general anesthesia with airway intubation or monitored anesthesia care without airway intubation. We examined cervical spine radiographs obtained up to 2 years before surgery and determined airway management techniques used during surgery. Results: Overall, 215 patients with RA underwent 217 individual surgeries requiring anesthesia; of these, 176 (82%) underwent general anesthesia with airway management with direct laryngoscopy in 83%, fiber-optic intubation in 10%, and laryngeal mask in 7%. Ninety-two (52%) of the patients receiving airway management had radiographs available for cervical spine evaluation; of these, only 7 (8%) had complete radiographic examinations with which to evaluate possible atlantoaxial subluxation. Eighteen (20%) of the 92 patients receiving airway management had radiographic evidence of cervical spine abnormality. Multiple regression models were conducted to evaluate the association of patient demographics and airway management technique used and showed that the use of fiber-optic intubation or laryngeal mask was not influenced by radiographic results. A difficult oropharyngeal class/glottic visualization grade (3 or 4) as determined by the anesthesiologist was the only statistically significant predictor of fiber-optic intubation or laryngeal mask use. Conclusions: Cervical spine abnormalities were frequently noted in patients who underwent general surgery but did not influence the choice of airway management. Future prospective studies evaluating the utility of cervical spine radiographs in patients with RA and practice guidelines are needed to ensure appropriate and cost-effective perioperative cervical evaluation and management of patients with RA.